More defamation of radiosurgery....

[jamie]

A member recently posted this interview of a House surgeon, Dr. Hitselberger, in which the doctor, when asked about radiosurgery, took the opportunity to make some pretty ridiculous statements, IMO. Since it was posted in the microsurgery section, I felt it appropriate to discuss that particular response in the radiosurgery forum, to try and avoid flaming from surgery patients who feel the need to parrot this misinformation (not meaning Jeff, who only posted the link to an interview he found interesting ).

Here's what was said (with my interjections added, of course).....

Beck: Dr. Hitselberger, can you please share your thoughts on Gamma Knife, Proton Beam and related radiographic treatments for skull base tumors?

Hitselberger: Sure, Great topic! There are a number of things to consider with Gamma Knife and other radiologic therapies like Proton Beam…. First, radiologic therapies don’t remove tumors. If the tumor grows, or the treatment is not successful, when we go in to remove the tumor surgically, it’s a bigger problem. By the time we operate, additional time has gone by and the tumor might be larger. Also, the scarring which results from radiologic treatment makes it more difficult to remove the tumor surgically because the capsule is harder to define and the tumor can be more adherent to healthy brain or other cranial nerve tissue.

First misleading statement, in their own recently published study on the topic, House stated it may be more difficult to remove the tumor after radiation, and that it was not more difficult in every case, but that's not what this doc is insinuating here, is it? Also, tumors may be more difficult to remove following a regrowth after surgery, for the same reason, scar tissue.

Another serious, yet extremely rare issue, is the tumor can actually change it’s biologic characteristics from benign to malignant following radiologic therapy. We have seen radiated tumors, on rare occasion, which have changed to malignant.

At least he was honest enough to say that this is extremely rare. However, nobody is really sure if in the very few cases in which a previously thought benign tumor turned malignant, if the tumor didn't have a malignant component all along. AN's have turned malignant after surgery as well, when the biopsied tissue showed benign. In those cases the surgeons say the tumor lkely had a portion that was malignant all along, so why do they say radiosurgery causes the tumor to change?

Radiologic treatment has another important issue and that has to do with recurrence. We’ve probably seen some 50 cases in which tumors have re-grown, it’s not just an odd one or two cases, there are quite a few around and I think our series is probably the largest in the world. We hope to publish that paper late in 2004, or in 2005, detailing our findings.

This actually promotes radiosurgery IMO, of all the surgeries they do at House, only about 50 have been regrowths following radiosurgery? Not bad considering the tens of thousands of patients who have had radosurgery in the U.S. alone. And it is the odd one or two cases when you look at these cases by the hundred. Published, peer reviewed studies consistently show control rates over 95%, what this doc is saying pretty much supports that, though unintentionally.   

On that same issue, when people have radiologic therapy, they need to be followed by radiographic studies every year, and that’s not a great thing either.

Only for the first couple years, then it changes to every two years, then every three to five. After five years, it is almost unheard of for the tumor to start growing again, and the vast majority have shrank significantly. I suspect alot of patients stop having MRI's all together by 10 years. Also, it is recommended that surgery patients have follow ups for life as well, as regrowth is nearly equal between the two treatments options.

Another issue, which few people think about, is getting health or life insurance. The issue is -- almost no one will insure you after radiologic treatment, because you still have a brain tumor -- at least that’s what I’ve heard from underwriters.

I work fo a major insurance company, and that is simply not the case. Radiosurgery is considered proven and effective for benign and malignant brain tumors, and is fully covered. If it were the case that radiosurgery is not curative like this doc is trying to say, we would NOT pay nearly $30,000 for it, only to have to pay for surgery down the road. 

Lastly, radiation therapy doesn’t cure benign tumors anywhere else in the body, so I’m not really sure why people try to apply it to acoustic neuromas, it’s just not a great idea most of the time.

There are so many things wrong with this it's hard to find where to start, first radiosurgery has not until very recently been used anywhere else in the body, it just couldn't be done with other machines. CyberKnife is having great success all over the body. Second, is this medical professional saying that ALL benign tumors share the same biology, from schwannomas to meningomas, from warts to moles? That's laughable. Different kinds of tumors, benign or malignant, have different biological make ups, different cells, etc. Some kinds are more radiosensitive than others, and a professional who performs radiosurgery can make the determination as to whether radiosurgery is a good option or not. The doctor who did my CyberKnife has a PhD in tumor biology and immunology, I guess somebody should have told him all benign tumors are the same. 

So all-in-all, I think Gamma Knife and Proton Beam therapies are interesting, and they have their place in certain, selected, unusual situations, but I think surgical removal is usually the preferred treatment. In fact, I can only recall referring one patient for radiotherapy, and that was a very unusual case.

So which is it? Does it work or doesn't it? Is it only effective in "certain, selected, unusual situations"? Of course surgical removal is the preferred treatment, they're surgeons.


 
http://www.audiologyonline.com/interview/displayarchives.asp?interview_id=315

[daylight]

This is directly from House's website under Stereotactic Irradiation.

Since its introduction in 1969, the gamma unit has been used to treat vestibular schwannomas based upon these principles. Initially utilizing high marginal doses and CT planning, the complications reported from experienced centers far exceeded those reported from microsurgical centers of excellence (12). With the improved technology of MR imaging for treatment planning, and the gradual empirical reduction in marginal dosing, the complication rates have reached levels comparable to those reported by microsurgical centers of excellence.

They admit that with new methods, complication rates are the same as with surgery. I.m wondering if they aren't better.  At least you don't have to worry about not waking up from anesthesia!
Sue B.

[Mark]

Jamie,

Well, here's my opinion which obviously others can differ with

1) when one has established a world class reputation for surgical ressection of AN's and
2) AN's are an extremely profitable surgery since they involve a craniotomy procedure on generally very healthy patients, thus having a shorter stay for the DRG code reimbursement.
3) which creates a cash generating niche for a community hospital in CA ( where 50% of all hospitals currently are in the red on operating costs to revenue)
4) it might be prudent to project information that would discourage new patients from considering a non surgical "competitive" approach, even if that information conflicts the published results of virtually every academic teaching center of excellence in neurosurgery relative to the basic viability of that approach.

One can be a tremendous option for those chosing to pursue a surgical solution and NOT necessarily be a good or credible source in providing information to evaluate both options.

Just my 2 cents

Mark

PS: I have been in the medical industry for 25 years , the last 13 in CA if any one wonders on what basis I made points 2 & 3

[Ned]

I do quite a bit of financial planning with physicians and when they learned of my AN, and the fact I used Radiation to treat, the overwhelming majority were very surprised that I didn't choose surgery because of all the negatives we all hear about radiation.

[jamie]

Those negatives are being disproved time and time again. And we (the patients) will continue to make that known. All newly diagnosed patients out there deserve correct, medically documented information to base their treatment decisions on.

[Ned]

I totally agree, my post was just to show how prevalent the lack of knowledge is among physicians that don't  work in this area.  During my research, it was totally consistent, the surgeons basically said radiation was voodoo science, even had one prominent surgeon say it would be "criminal" to treat me with radiation.  Similar remarks from the House Institute.  This was 2 years ago and I haven't been on this site since the change in format, has this difference improved?  Unfortunately I hear of so many people rushing to surgery to just get this thing out of my head.  What disturbs me is that in many cases they can't get it all out, and don't know if they can or not until they go in.  Those 4 months investigating were the hardest of my life.

[jamie]

Yeah, isn't that the way it always is? Anytime a "new" technology arises, there are many who refuse to embrace it, until eventually they really have no choice. More and more surgeons are coming around to the radiosurgery option I think, there are a few that will fight to the end though Im sure.